1. Risk Factors for Inadequate Treatment of Cancer-Related Pain Among African American and Latino Cancer Patients Karen O. Anderson, PhD, MPH Department of Symptom Research The University of Texas M.D. Anderson Cancer Center

2. Institute of Medicine Report on Unequal Treatment l Racial and ethnic disparities in healthcare exist. These disparities are consistent and extensive across a range of medical conditions and health care services…they are associated with worse outcomes…and therefore, are unacceptable. Institute of Medicine Report on Unequal Treatment, 2002

3. Documenting the Problem Research findings from the 80’s found that: l Many cancer patients have significant pain for a long period of time. l Cancer pain is often poorly treated.

4. Results From ECOG Pain Studies More than one-third with metastatic cancer reported pain that interfered with their function. More than one-third with metastatic cancer reported pain that interfered with their function. Forty percent of patients with pain were not prescribed analgesics strong enough to effectively treat their pain. Forty percent of patients with pain were not prescribed analgesics strong enough to effectively treat their pain. Cleeland et al, NEJM, 1994 Cleeland et al, NEJM, 1994

5. Patients at Risk for Inadequate Pain Management l Patients cared for at minority treatment centers were three times more likely to be undermedicated with analgesics. l Discrepancy between patient and provider estimates of pain severity.

6. ECOG Minority Study: Findings Negative Pain Management Index –Majority patients: 38% –Minority patients: 65% –Cleeland et al, Annals Internal Med, 1997

7. PREMO Goals Identify pain management needs of African American and Hispanic patients with cancer and pain. Develop culturally appropriate patient education materials. Conduct a clinical trial to evaluate the efficacy of an educational intervention.

8. PREMO Sites Houston –UT MD Anderson Cancer Center –Two Harris County Hospitals –VAMC Miami –One County Hospital

9. Pain-Related Variables among Minority Cancer Patients Patient Group Percent with severe pain African American72% Hispanic57%

10. Objectives of the Clinical Trial To determine if patient education improves pain control in African American and Hispanic patients with cancer-related pain To determine if patient education reduces the impact of pain To determine if patient education improves quality of life –Anderson et al., JCO, 2004

11. Randomized Clinical Trial Pain Education –Video and booklet on cancer pain and pain treatment –Gender and heritage specific materials –How to report pain –How to take analgesics Control Group –Nutrition video and booklet –Controls for an educational treatment –Nutrition for cancer patients –English and Spanish versions

12. Educational Materials Emphasize pain relief Teach how to report pain Model patient communication Reduce fears of opioids Cultural issues

13. Eligibility Criteria Diagnosis of cancer Pain due to cancer or cancer treatment Pain worst score of 4 or greater on BPI African American or Hispanic heritage ECOG performance status of 0, 1, or 2 No current palliative radiotherapy No major surgery within past 30 days

14. Assessment Schema Intake (T1, Day 1) –BPI - long form –SF-12 Health Survey –Pain Control Scale –MD Pain Assessment Time 2 (Day 15-28) –BPI - short form –SF-12 Health Survey –Pain Control Scale –MD Pain Assessment

15. Assessment schema Time 3 (week 6-7) –BPI - short form –SF-12 Health Survey –Pain Control Scale –MD Pain Assessment –Compliance form Time 4 (week 8-10) –BPI - short form –SF-12 Health Survey –Pain Control Scale –MD Pain Assessment –Compliance form

16. Accrual in the Clinical Trial (n = 97) 36 breast cancer patients (39%) 61 cancer patients with other solid tumors or hematological malignancies –23% GI –18% lung –10% GU/Gyn –4% head and neck –6% other

17. Demographics 66% female 39% married, 61% single 54% Hispanic, 46% African American 52% high school education 46% disabled, 15% retired, 11% jobs –20% homemakers, 9% other

18. Disease-related Variables 63% good ECOG performance status –54% education, 72% control group 66% chemotherapy 14% hormonal therapy 65% metastatic disease 66% severe pain 52% pain > 6 months

19. Mean Pain Severity over Time for Education and Control Groups

20. Mean Pain Severity over Time for African American Patients

21. Mean Pain Interference over Time for Education and Control Groups

22. Perceived Pain Control over Time for Education and Control Groups

23. Mean SF-12 Physical Component Summary Scores

24. Mean SF-12 Mental Component Summary Scores

25. Physicians’ Underestimates of Patients’ Pain GroupTime 1Time 2Time 3Time 4 Education 77%67%87%88% Control68%70%52%75%

26. Negative Pain Management Index GroupTime 1Time 2Time 3 Education 60%32%50% Control49%38%42%

27. Conclusions Pain education did not improve pain intensity for Hispanic patients Pain education led to short-term reduction in pain intensity for African American patients No impact on perceived pain control or quality of life Individualized education or treatment protocols may be more beneficial

28. Why?

29. Top Barriers to Cancer Pain Management

30. Pain-Related Attitudes ItemHispanicAfrican American Caucasian Need more information 55%43%16% Need more medication 28%33%11% Need stronger medication 39%47%17%

31. Pain-Related Behaviors and Attitudes ItemHispanicAfrican American Caucasian Taking prn meds 62%66%60% Taking < 2 times/day 80%83%52% Side effects26%29%21% Overuse concern 36%22%

32. Pain-Related Attitudes ConcernAfrican American Hispanic Be strong93%76% Addiction79%59% Tolerance57%71% Not effective69%71% Not bother MD71%59%

33. Use of Alternative Treatments TechniqueAfrican American Hispanic Prayer83%47% Over the counter meds 33%35% Special teas or herbs 25%18% Relaxation33%12% Vitamins25%12%

34. Communication “The doctor understands me because he speaks Spanish.” “If I continue to have pain, the doctor said contact me as soon as you can.” “Wow, what a relief.”

35. Communication “You don’t remember everything...It would be good to have something written.” “If the doctors or nurses had more time… or to have a stable nurse.” “She uses a lot of big words that I don’t understand.”

36. Concerns about Pain Medications “Does one die when one takes morphine?” “The doctor said don’t take too much if you don’t have to.” “They tell me that the medicine is addictive.”

37. Risk Factors for Inadequate Pain Treatment Marital Status –Single: 74% under treated –Married: 58% under treated

38. Risk Factors for Inadequate Pain Treatment Ethnicity –Latino patients: 59% under treated –African American patients: 48% under treated –P = 0.10

39. Risk Factors for Inadequate Pain Treatment Performance Status –Poor performance status: 36% under treated –Good performance status: 45% under treated –P = 0.11

40. Risk Factors for Inadequate Pain Treatment Physician Assessment –Inadequate: 58% under medicated –Adequate: 37% under medicated

41. Conclusions Pain interventions for underserved minority patients must target physicians and patients Standardized pain assessment Pain treatment guidelines Pain education for patients needs to be individualized Specific barriers can be identified

42. Eliminate Disparities “Our greatest opportunities for reducing health disparities are in empowering individuals to make informed health care decisions and in providing the skills, education, and care necessary to improve health. The underlying premise of Healthy People 2010 is that the health of the individual is inseparable from the health of the larger community.” David Satcher, MD, PHD

43. Research Team Charles S. Cleeland, PhD Richard Payne, MD Guadalupe Palos, RN, LMSW, DrPH Tito Mendoza, PhD Vicente Valero, MD Arlene Nazario, MD Stephen Richman, MD